Cost of specialized addiction treatment of clients with fetal alcohol spectrum disorder in Canada

  • Svetlana Popova1, 2, 3, 4Email author,

    Affiliated with

    • Shannon Lange1, 2,

      Affiliated with

      • Larry Burd5,

        Affiliated with

        • Karen Urbanoski1, 2 and

          Affiliated with

          • Jürgen Rehm1, 2, 4, 6

            Affiliated with

            BMC Public Health201313:570

            DOI: 10.1186/1471-2458-13-570

            Received: 14 January 2013

            Accepted: 7 June 2013

            Published: 11 June 2013

            Abstract

            Background

            Individuals with Fetal Alcohol Spectrum Disorder (FASD) constitute a special population that may be at particularly high risk for substance use. The purpose of the current study was to estimate the utilization of specialized addiction treatment services (SATS) and the associated cost, as a part of the total cost of health care associated with FASD in Canada.

            Methods

            The current study was a modeling study. Data on SATS by lifetime mental disorder status were obtained from the Drug and Alcohol Treatment Information System (DATIS) in Ontario, Canada for 2010/11. The number of clients with FASD who received SATS in Ontario in 2010/11 was estimated, assuming that approximately 37% (confidence interval: 21.6%-54.5%) of individuals with FASD abuse or are addicted to alcohol and/or drugs and that their utilization rate of SATS is the same as those for people with a lifetime mental disorder. The data from DATIS was then extrapolated to the total Canadian population.

            Results

            The cost of SATS for clients with FASD in Canada in 2010/11 ranged from $1.65 million Canadian dollars (CND) to $3.59 million CND, based on 5,526 outpatient visits and 9,529 resident days. When the sensitivity analysis was performed the cost of SATS ranged from $979 thousand CND to $5.34 million CND.

            Conclusions

            Special attention must be paid to at-risk groups of individuals such as those with FASD, in order to reduce the likelihood of the development of co-morbid substance abuse problems, and thus, reducing the overall burden on Canadian society.

            Keywords

            Fetal alcohol syndrome Fetal alcohol spectrum disorder Addiction Specialized treatment Utilization Cost Canada

            Background

            This study is a part of a large economic study on the estimation of the burden and cost associated with Fetal Alcohol Spectrum Disorder (FASD) in Canada [1, 2]. FASD is a non-diagnostic term that encompasses four alcohol-related clinical diagnoses, including: Fetal Alcohol Syndrome (FAS), Partial FAS, Alcohol-Related Neurodevelopmental Disorder, and Alcohol-Related Birth Defects.

            Individuals with FASD have an increased vulnerability to certain risk factors, which put them at a higher risk for substance use/abuse problems, as a result of the damage caused to their central nervous system due to their exposure to alcohol prenatally. This damage manifests as developmental delays, cognitive impairments, mental disorders, high rates of incarceration and an increased rate of substance abuse [35].

            The impairments expressed by individuals with FASD typically lead to high-risk behaviours, such as alcohol/drug abuse or an increased likelihood of being in high-risk situations (increasing the chance of being exposed to alcohol and/or drugs). Currently, there are not many epidemiological studies reporting on the prevalence of substance use/abuse among individuals with FASD. However, the literature does indicate that a disproportionate number of individuals with FASD will have problematic substance use issues at some point in their lives [6]. For instance, Famy et al. [7] reported a prevalence of 55% for alcohol/drug dependence among their sample of individuals with FAS. Additionally, Clark and colleagues [8] and Streissguth and colleagues [9] reported that 22% and 35% of their respective cohorts of individuals with FASD had problems with alcohol/drugs. Lastly, in a study conducted by Grant and colleagues [10], about 68% of women with FASD had reported abusing alcohol and 79% had used illegal drugs in the 10 months prior to being admitted into a community program.

            There are a few potential explanations for the high prevalence of substance use among individuals with FASD: 1) a biological vulnerability to substance use may exist; 2) individuals with FASD may use substances to self-medicate; and 3) individuals with FASD tend to have difficulties with impulse control, making them susceptible to developing a substance use disorder [11]. Regardless of the reason for such high rates of co-occurring substance use problems and FASD, this population places a greater demand on treatment service providers, given that they suffer from multiple co-morbid mental disorders [8, 12, 13].

            Prenatal alcohol use exposes three generations to the harmful effects of alcohol (the mother, the fetus, and the germ line of the fetus). Increased rates of substance abuse increase the risk for additional familial cases of FASD (multiple affected siblings), and increase the risk of generational FASD [3, 14]. Therefore, it is also important to address the issue of women of childbearing age with FASD so that the generational effects of FASD can be halted.

            In Canada, as is common elsewhere, specialized addiction treatment services provide a continuum of care, from assistance with symptoms of withdrawal through to active treatment and continuing care [15]. They vary, however, in their capacity for assisting clients with co-occurring disorders [15, 16], which would include complications arising from FASD among others. Prior research suggests that people with co-morbid substance use and mental disorders have a more complicated trajectory of service use, including higher rates of relapse and readmission to addiction treatment [1722]. Given the high-risk nature of FASD for multiple health and social comorbidities, it is of interest to understand their representation in the specialized addiction treatment system.

            The purpose of this study was to estimate the use of specialized addiction treatment services and the associated cost, as a part of the total cost of health care associated with FASD in Canada.

            Methods

            Since there is great uncertainty regarding the true prevalence of people with FASD in the general population, and the prevalence of people with FASD who abuse or are addicted to substances, specifically, in combination with the lack of FASD-specific data pertaining to specialized addiction treatment services in Canada, several important assumptions were used and sensitivity analyses were conducted, as described step-by-step below.

            Source of data

            Data were obtained from the Drug and Alcohol Treatment Information System (DATIS; http://​www.​datis.​ca), which monitors the use of specialized addiction treatment services by people in Ontario, Canada. Started in 1992, DATIS collects data on the numbers and types of clients entering publicly funded specialized addiction treatment across the province. This system includes approximately 200 treatment programs, administered by 170 agencies [23, 24]. The types of services provided by each agency can vary; some agencies provide a specific type of service (e.g., assessment and referral, withdrawal management, individual counseling), while others provide a comprehensive mix of services. Regardless of the type of service, all services are delivered free-of-charge to Ontario residents (i.e., they are covered by the province’s universal health insurance plan). Agency-level participation has been over 95% since 2000.

            The DATIS database is structured by admissions to treatment programs, such that a new admission is triggered when a client enters a new treatment program or transitions between two different types of services. Since 2002, data entry has been supported by a web-based user platform accessible by all frontline clinicians working in the designated programs across the province. Data entry fields correspond to 66 data elements that are mandatory for all admissions. Sociodemographic characteristics, information on substance use, and other treatment-related factors (e.g., referral source, current and past diagnoses of mental disorders, and treatment mandates) are entered by the service provider at admission, typically following the first face-to-face encounter with the client. Unique identifiers for individual clients and agencies are generated automatically by the software, as is a variable documenting the type of treatment program or service (i.e., outpatient, residential or residential withdrawal management). Details on service use, including the number of outpatient visits and days or residential care, are entered by service providers at discharge. Data are stored on a central server located at the Centre for Addiction and Mental Health in Toronto, Canada.

            Study population

            All admissions corresponding to services received during the 2010/11 fiscal year (April 1, 2010 to March 31, 2011; N=91,333) were extracted for analysis. This included all admissions occurring during the fiscal year, as well as those where treatment had started prior to April 1, 2010, but that had continued into the study period. As noted above, an admission corresponds to a particular type of service, with movement between types of services (e.g., from a residential service to an outpatient program) counted as separate admissions. Multiple admissions per individual client were included. This was done to ensure that the most complete estimates of the volume and costs of services delivered during the study period were obtained. Therefore, it is important to note that each admission does not necessarily represent a separate individual, as one individual can have multiple admissions.

            Data elements

            In order to determine whether or not a client has had a “lifetime mental disorder” (i.e., a diagnosed mental disorder at any point within their lifetime; response: yes versus no), the question “Have you ever been diagnosed by a qualified mental health professional with a mental disorder within the last 12 months or within your lifetime?” was asked to each client at the beginning of treatment.

            Age groups, divided into 5-year intervals from 14 years of age and younger to 70 years of age and older, were generated from the clients’ date of birth. All variables (lifetime mental disorder, date of birth, and sex) were self-reported by the clients during their initial clinical encounter.

            Service type (i.e., outpatient, residential treatment, or residential withdrawal management, automatically generated in DATIS) was abstracted, as were the number of visits for outpatient treatment and days in residential treatment and residential withdrawal management. The numbers of visits and days of care, entered by service providers based on client charts, provide estimates of the volume of services received. For admissions that began prior to or ended after the 2010/11 fiscal year, only those visits/days that occurred within the study period were counted. To comply with Personal Health Information Protection Act (2004), cells with values less than 6 were redacted and replaced with "<6".

            Estimation of the prevalence of clients with FASD in specialized addiction treatment and their utilization of these services

            Number of people with FASD in Canada

            The prevalence of FAS and FASD are currently unknown in Canada. However, the most commonly cited rough estimates are 1 per 1,000 for FAS [25], and 9 per 1,000 for FASD [26]. Using data on the general population, by age group and sex, of Canada in 2010 [27], and assuming a prevalence of 9 per 1,000 for FASD [26], the number of people with FASD in Canada was estimated.

            Number of people with FASD who abuse or are addicted to alcohol and/or drugs

            In order to estimate the number of clients with FASD who had received specialized addiction treatment services in Canada in 2010/11, the prevalence of individuals with FASD who abuse or are addicted to alcohol and/or drugs was calculated based on available epidemiological studies [710] using the meta-analysis technique described below.

            Meta-analysis

            Prevalence data from the epidemiological studies concerning alcohol/drug abuse/use/dependence among those with FASD were transformed into log-odds for the meta-analysis [28]. Log-odds estimates were weighted by the inverse variance of the log-odds transformed prevalence. Heterogeneity between studies was assessed using the Cochrane Q-test and the I2 statistic [29, 30]. The prevalence estimates were pooled using the Mantel-Haenszel method, using a random-effects model [31].

            Publication bias was tested by: 1) visually inspecting a funnel plot for skewed distribution, 2) using a ranked correlation test [32], and 3) employing a weighted regression test [33]. Publication bias was then adjusted for using the trim and fill method [34].

            Number of people with FASD who utilized specialized addiction treatment services and their rate of utilization in 2010/11

            In order to calculate the number of people with FASD who utilized specialized addiction treatment services in 2010/11, it was assumed that the rate of specialized addiction treatment services among this population (individuals with FASD) was the same as the rate among individuals with a lifetime mental disorder. This assumption is based on a very high prevalence of co-morbid mental illness reported among individuals with FASD [7, 9, 35, 36]. Based on the authors’ comprehensive literature review (Popova et al., unpublished), the weighted mean for mental retardation (International Classification of Diseases, version 10 [ICD-10] category: F70-F79) among individuals with FASD is 48% (95% confidential interval [CI]: 44.4%-51.4%) and for disorders of psychological development (ICD-10 category: F80-F89) is 37% (95% CI: 35.9%-39.0%).

            In order to estimate the rate of utilization of specialized addiction treatment services for individuals with a lifetime mental disorder, the number of specialized addiction treatment services admissions for individuals with a lifetime mental disorder was divided by the total number of individuals with a mental illness in Ontario (reported by the Ministry of Health and Long-Term Care [36] and Health Canada [37]).

            In turn, in order to estimate the total number of admissions, and visits/days, by treatment type, among clients with FASD for all of Canada, the distribution for each treatment type among clients who received specialized addiction treatment services in the province of Ontario was used and extrapolated to the total Canadian population. This approach is justifiable given that Ontario represents about 39% of the total population of Canada.

            Estimation of costs

            The cost for specialized outpatient treatment ranged from $60 to $109 per service and for residential treatment ranged from $138 to $314 per resident day in Canada in 2010/11 (Martin et al., in progress). These unit costs are estimated based on the costs reported by five Local Health Integration Networks (LHINs) across Ontario. The overall estimates are inclusive of the cost of supervision, facility costs, salaries, and other sundry expenses. The ranges reported account for the differences in costs incurred due to the number of spots/beds available (capacity), whether the treatment is hospital based or community based, the intensity of activities provided, and staff professionalism (which affects both their salaries and the scope of the staff complement).

            The corresponding costs - for outpatient treatment: $60 and $109 per service as the lower and upper estimates, respectively; and for residential treatment: $138 and $314 per resident day as the lower and upper estimates, respectively - were applied to substance-attributable specialized outpatient visits and residential days, in order to obtain the total costs of such services for clients with FASD.

            All cost figures are presented in Canadian dollars.

            Sensitivity analysis

            Due to a very limited number of existing epidemiological studies, there is great uncertainty regarding the prevalence of individuals with FASD who abuse or are addicted to alcohol and/or drugs. As described above, the weighted mean of 37% (CI: 21.6%-54.5%), which was calculated based on the available epidemiological studies [710] was used in the main analysis. In addition, two separate analyses were performed assuming that 22% (as the lower estimate) and 55% (as the upper estimate; both are based on the estimated CI) of individuals with FASD abuse or are addicted to alcohol and/or drugs.

            Results

            Calculation of the rate of specialized addiction treatment service among individuals with a lifetime mental disorder

            Given that 20% of the population, age 12 and over, of Ontario [37] reported a mental health diagnosis such as mood disorders, anxiety disorders, and/or schizophrenia in 2005 and based on the population size of Ontario (13,227,791 [27]), the total number of individuals who suffer with a mental illness in Ontario was calculated to be 2,645,558. The rate of 20% has also been reported for all of Canada [38].

            In order to estimate the rate of utilization of specialized addiction treatment services for individuals with a lifetime mental disorder, the number of specialized addiction treatment services admissions for clients with a lifetime mental disorder (N=37,164; obtained from DATIS for 2010/11) was divided by the total number of individuals with a mental illness in Ontario (2,645,558), resulting in the rate of 1.4%. The rate of utilization of specialized addiction treatment services for individuals without a lifetime mental disorder was estimated to be almost three times lower (i.e., 0.5%).

            Estimation of the number of clients with FASD who received specialized addiction treatment services in Ontario and Canada in 2010/11

            Using data on the general population of Ontario in 2010 (13,227,791 [27]) and assuming a prevalence of 9 per 1,000 for FASD [26], it was estimated that there were 119,050 individuals with FASD in Ontario in 2010/11.

            Results of the meta-analysis revealed that approximately 37% of individuals with FASD abuse or are addicted to alcohol and/or drugs. Applying 37% to 119,050 individuals with FASD, results in 44,049 of individuals with FASD who abuse or are addicted to alcohol and/or drugs in Ontario in 2010/11. Assuming that the utilization rate of specialized addiction treatment services among individuals with FASD is the same as those for people with a lifetime mental disorder (1.4%; see above), the number of admissions for clients with FASD who received specialized addiction treatment services in Ontario in 2010/11 was estimated to be 617.

            Similarly, using data on the general population of Canada in 2010 (34,126,181 [27]) and an assumed prevalence of 9 per 1,000 for FASD [26], it was estimated that there were 307,136 individuals with FASD in Canada in 2010/11.

            Again, under the assumption that approximately 37% (113,640) of individuals with FASD abuse or are addicted to alcohol and/or drugs and that the utilization rate of specialized addiction treatment services among individuals with FASD is the same as those for people with a lifetime mental disorder (1.4%; see above), the number of admissions for clients with FASD who received specialized addiction treatment services in Canada in 2010/11 was estimated to be 1,591.

            Service utilization and estimation of the cost associated with addiction treatment services for clients with FASD

            Based on the service rates obtained from DATIS, and the assumption that individuals with FASD have the same utilization rates as those of individuals with a lifetime mental disorder, it was estimated that there were 1,591 admissions in total in Canada (546 for outpatient, 189 for residential, and 856 for withdrawal management) among clients with FASD. These admissions resulted in 5,526 outpatient visits, and 9,529 residential days; the associated cost was estimated to range from $1.65 million to $3.59 million.

            The number of admissions, visits/days in outpatient treatment, residential treatment, and residential withdrawal management services and costs among clients with FASD by age groups and sex in Ontario and Canada in 2010/11 are presented in Tables 1, 2, and 3, respectively.
            Table 1

            Estimated number of admissions, visits and cost of outpatient treatment services among clients with FASD by age groups and sex in Ontario and Canada in 2010/11

            Gender

            Age group

            Cost

             

            14 and under

            15-19

            20-24

            25-29

            30-34

            35-39

            40-44

            45-49

            50-54

            55-59

            60-64

            65-69

            70 and over

            All ages

            Lower estimate

            Upper estimate

            Clients with FASD in Ontario

            Number of admissions

                          

            Male

            <6

            15

            13

            11

            12

            11

            13

            13

            10

            7

            <6

            <6

            <6

            112

              

            Female

            <6

            10

            11

            13

            13

            12

            11

            12

            8

            <6

            <6

            <6

            <6

            99

              

            Total

            <6

            25

            24

            24

            25

            23

            24

            25

            18

            11

            6

            <6

            <6

            212

              

            Number of visits

                          

            Male

            17

            98

            91

            93

            124

            124

            143

            137

            111

            90

            29

            14

            7

            1,078

            $64,670

            $117,484

            Female

            23

            82

            106

            143

            127

            121

            127

            147

            79

            56

            31

            15

            9

            1,065

            $63,914

            $116,111

            Total

            40

            180

            197

            237

            250

            245

            270

            283

            190

            146

            60

            29

            16

            2,143

            $128,585

            $233,595

            Clients with FASD in Canada

            Number of admissions

                          

            Male

            6

            38

            32

            29

            31

            29

            34

            33

            26

            18

            8

            <6

            <6

            290

              

            Female

            <6

            26

            30

            34

            32

            30

            28

            31

            20

            12

            6

            <6

            <6

            256

              

            Total

            10

            63

            62

            63

            64

            59

            61

            64

            46

            29

            14

            6

            <6

            546

              

            Number of visits

                          

            Male

            43

            251

            236

            241

            319

            320

            369

            353

            286

            232

            75

            37

            18

            2,779

            $166,759

            $302,946

            Female

            59

            212

            272

            370

            326

            312

            327

            378

            204

            145

            81

            38

            22

            2,747

            $164,810

            $299,405

            Total

            102

            463

            508

            610

            645

            632

            696

            731

            490

            377

            156

            74

            40

            5,526

            $331,569

            $602,350

            FASD: Fetal Alcohol Spectrum Disorder.

            Note. Cells with values less than 6 were redacted and replaced with "<6".

            Table 2

            Estimated number of admissions, resident days and cost of residential treatment services among clients with FASD age groups and sex in Ontario and Canada in 2010/11

            Gender

            Age group

            Cost

             

            14 and under

            15-19

            20-24

            25-29

            30-34

            35-39

            40-44

            45-49

            50-54

            55-59

            60-64

            65-69

            70 and over

            All ages

            Lower estimate

            Upper estimate

            Clients with FASD in Ontario

            Number of admissions

                          

            Male

            <6

            <6

            <6

            <6

            6

            7

            6

            6

            5

            <6

            <6

            <6

            <6

            44

              

            Female

            <6

            <6

            <6

            <6

            <6

            <6

            <6

            <6

            <6

            <6

            <6

            <6

            <6

            29

              

            Total

            <6

            <6

            8

            11

            10

            10

            9

            10

            7

            <6

            <6

            <6

            <6

            73

              

            Number of days

                          

            Male

            <6

            99

            158

            200

            234

            264

            235

            292

            223

            93

            41

            9

            7

            1,855

            $256,056

            $582,621

            Female

            <6

            84

            104

            174

            143

            116

            114

            102

            90

            49

            10

            <6

            <6

            989

            $136,472

            $310,524

            Total

            7

            183

            262

            374

            376

            381

            349

            394

            313

            142

            51

            12

            7

            2,844

            $392,529

            $893,145

            Clients with FASD in Canada

            Number of admissions

                          

            Male

            <6

            6

            11

            14

            15

            17

            14

            16

            13

            6

            <6

            <6

            <6

            115

              

            Female

            <6

            <6

            10

            13

            10

            9

            9

            9

            <6

            <6

            <6

            <6

            <6

            74

              

            Total

            <6

            10

            21

            27

            25

            25

            23

            25

            18

            9

            <6

            <6

            <6

            189

              

            Number of days

                          

            Male

            13

            254

            407

            515

            603

            682

            607

            753

            576

            241

            105

            24

            18

            4,785

            $660,269

            $1,502,351

            Female

            <6

            217

            267

            450

            368

            300

            294

            263

            231

            126

            27

            6

            <6

            2,550

            $351,908

            $800,718

            Total

            18

            471

            675

            965

            971

            982

            900

            1,016

            807

            367

            131

            30

            19

            7,335

            $1,012,177

            $2,303,069

            FASD: Fetal Alcohol Spectrum Disorder.

            Note. Cells with values less than 6 were redacted and replaced with "<6".

            Table 3

            Estimated number of admissions, resident days and cost of residential withdrawal management services among clients with FASD age groups and sex in Ontario and Canada in 2010/11

            Gender

            Age group

            Cost

             

            14 and under

            15-19

            20-24

            25-29

            30-34

            35-39

            40-44

            45-49

            50-54

            55-59

            60-64

            65-69

            70 and over

            All ages

            Lower estimate

            Upper estimate

            Clients with FASD in Ontario

            Number of admissions

                          

            Male

            <6

            7

            19

            29

            31

            28

            31

            30

            24

            14

            <6

            <6

            <6

            219

              

            Female

            <6

            <6

            15

            18

            16

            13

            14

            13

            10

            <6

            <6

            <6

            <6

            111

              

            Total

            <6

            12

            34

            47

            48

            42

            45

            43

            33

            19

            6

            <6

            <6

            332

              

            Number of days

                          

            Male

            <6

            20

            41

            61

            70

            83

            90

            88

            75

            30

            23

            <6

            <6

            587

            $80,941

            $184,169

            Female

            <6

            10

            35

            36

            40

            28

            36

            28

            29

            13

            <6

            <6

            <6

            264

            $36,455

            $82,948

            Total

            <6

            30

            76

            97

            110

            111

            126

            117

            104

            43

            28

            <6

            <6

            851

            $117,438

            $267,213

            Clients with FASD in Canada

            Number of admissions

                          

            Male

            <6

            18

            49

            74

            81

            73

            81

            77

            61

            37

            12

            <6

            <6

            566

              

            Female

            <6

            14

            37

            47

            42

            35

            36

            32

            25

            12

            <6

            <6

            <6

            287

              

            Total

            <6

            32

            87

            121

            123

            107

            117

            110

            86

            49

            16

            <6

            <6

            856

              

            Number of days

                          

            Male

            <6

            51

            105

            157

            180

            214

            232

            228

            194

            78

            60

            8

            7

            1,512

            $208,714

            $474,901

            Female

            <6

            26

            91

            94

            104

            73

            94

            73

            74

            33

            12

            <6

            <6

            681

            $94,003

            $213,891

            Total

            <6

            77

            196

            251

            285

            286

            325

            301

            268

            111

            72

            12

            9

            2,194

            $302,825

            $689,037

            FASD: Fetal Alcohol Spectrum Disorder.

            Note. Cells with values less than 6 were redacted and replaced with "<6".

            The total number of admissions, visits/days and costs of specialized addiction treatment services among clients with FASD for Ontario and Canada, as a whole, in 2010/11 are presented in Table 4 and Figures 1, 2 and 3 (FAS is figuratively presented separately).
            http://static-content.springer.com/image/art%3A10.1186%2F1471-2458-13-570/MediaObjects/12889_2013_5509_Fig1_HTML.jpg
            Figure 1

            Estimated number of admissions among clients with FASD (including FAS a ) in Canada 2010/11. a Estimated based on a prevalence of 1 per 1,000 [21].

            http://static-content.springer.com/image/art%3A10.1186%2F1471-2458-13-570/MediaObjects/12889_2013_5509_Fig2_HTML.jpg
            Figure 2

            Estimated number of visits/inpatient days among clients with FASD (including FAS a ) in Canada 2010/11. a Estimated based on a prevalence of 1 per 1,000 [21].

            http://static-content.springer.com/image/art%3A10.1186%2F1471-2458-13-570/MediaObjects/12889_2013_5509_Fig3_HTML.jpg
            Figure 3

            The overall estimated costs associated with specialized addiction treatment among clients with FASD (including FAS a ) in Canada 2010/11. LE: Lower Estimate. UE: Upper Estimate. a Estimated based on a prevalence of 1 per 1,000 [21].

            Table 4

            Estimated number of admissions, outpatient visits, resident days and costs of specialized addiction treatment services among clients with FASD in Ontario, and Canada in 2010/11

             

            Number of admissions, outpatient visits and resident days; associated cost (lower & upper estimate)

            Total population (2010)a

            Number of clients with FASD (based on a prevalence of 9 per 1,000)

            Types of specialized addiction treatment services

            Outpatient

            Residential

            Withdrawal

            Overall

            Ontario

            13,227,791

            119,050

                
             

            Number of admissions

              

            212

            73

            332

            617

             

            Number of visits

              

            2,143

              

            2,143

             

            Number of days

               

            2,844

            851

            3,695

             

            Cost (Lower estimate)

              

            $128,585

            $392,529

            $117,438

            $638,551

             

            Cost (Upper estimate)

              

            $233,595

            $893,145

            $267,213

            $1,393,953

            Canada (All provinces/territories)

            34,126,181

            307,136

                
             

            Number of admissions

              

            546

            189

            856

            1,591

             

            Number of visits

              

            5,526

              

            5,526

             

            Number of days

               

            7,335

            2,194

            9,529

             

            Cost (Lower estimate)

              

            $331,569

            $1,012,177

            $302,825

            $1,646,571

             

            Cost (Upper estimate)

              

            $602,350

            $2,303,069

            $689,037

            $3,594,456

            1) Sensitivity analysis, assuming 22% (lower estimate) of individuals with FASD suffer from addiction

            34,126,181

            307,136

                
             

            Number of admissions

              

            325

            112

            509

            946

             

            Number of visits

              

            3,286

              

            3,286

             

            Number of days

               

            4,361

            1,305

            5,666

             

            Cost (Lower estimate)

              

            $197,144

            $601,866

            $180,029

            $979,037

             

            Cost (Upper estimate)

              

            $358,145

            $1,369,464

            $409,626

            $2,137,235

            2) Sensitivity analysis, assuming 55% (upper estimate) of individuals with FASD suffer from addiction

            34,126,181

            307,136

                
             

            Number of admissions

              

            812

            281

            1,272

            2,365

             

            Number of visits

              

            8,214

              

            8,214

             

            Number of days

               

            10,903

            3,261

            14,165

             

            Cost (Lower estimate)

              

            $492,859

            $1,504,666

            $450,066

            $2,447,592

             

            Cost (Upper estimate)

              

            $895,361

            $3,423,661

            $1,024,064

            $5,343,086

            a Source: Statistics Canada [23].

            FASD: Fetal Alcohol Spectrum Disorder.

            Note. Columns may not add up due to rounding errors.

            Please note that the number of admissions, visits/days and costs of specialized addiction treatment services by province/territory among clients with FASD in 2010/11 are available from the authors upon request.

            On average, in Canada, there were per admission approximately 10 visits for outpatient treatment; 39 days for residential treatment; and 3 days for residential withdrawal management services.

            Further, it was estimated that in Canada in 2010/11 there were approximately 445 specialized addiction treatment services admissions of women of childbearing age (15–44) with FASD (Figure 4). These admissions resulted in 1,819 outpatient visits and 2,378 residential days (1,896 days in residential treatment, and 482 days in residential withdrawal treatment; Figure 5).
            http://static-content.springer.com/image/art%3A10.1186%2F1471-2458-13-570/MediaObjects/12889_2013_5509_Fig4_HTML.jpg
            Figure 4

            Estimated number of admissions among female clients of childbearing age with FASD in Canada 2010/11.

            http://static-content.springer.com/image/art%3A10.1186%2F1471-2458-13-570/MediaObjects/12889_2013_5509_Fig5_HTML.jpg
            Figure 5

            Estimated number of visits/inpatient days among female clients of childbearing age with FASD in Canada 2010/11.

            Sensitivity analysis

            Assuming that 22% (as the lower estimate) of individuals with FASD abuse or are addicted to alcohol and/or drugs, it was estimated that there were 946 admissions in total (325 for outpatient, 112 for residential, and 509 for withdrawal management) in Canada in 2010/11 - resulting in 3,286 outpatient visits and 5,666 resident days. The associated cost was estimated to range from $979 thousand to $2.14 million (Table 4).

            Assuming that 55% (as the upper estimate) of individuals with FASD abuse or are addicted to alcohol and/or drugs, it was estimated that there were 2,365 admissions in total (812 for outpatient, 281 for residential, and 1,272 for withdrawal management) in Canada in 2010/11. These admissions resulted in 8,214 outpatient visits and 14,165 resident days. The associated cost was estimated to range from $2.45 million to $5.34 million (see Table 4).

            Discussion

            It is clear from the current estimated costs associated with specialized addiction treatment services for clients with FASD in Canada that substance abuse problems among this specific population place an additional economic burden on Canadian society. It is important to note that the cost of specialized addiction treatment services, estimated in the current study, is only a part of the total cost of health care associated with FASD [1, 2, 39, 40].

            As the results indicate, individuals with a co-morbid mental disorder represent a large portion of those utilizing specialized addiction treatment services in Canada – about 40%. This has also been supported by previous research [4143]. Within this group are those with FASD, which represent a population that is high-risk for concurrent mental health disorders [7, 12, 13, 44, 45]. Research shows that such high-risk populations with co-morbid mental disorders have higher rates of relapse and readmission to treatment, and thus, have a more complicated trajectory of service use and place a greater demand on service providers [1722].

            Individuals with FASD who abuse substances constitute a special population for service providers for multiple reasons. First, all individuals with FASD have an affected family member and many will have multiple affected family members [14, 46, 47]. Second, nearly all individuals with FASD have neurocognitive impairments that will affect their response to substance abuse treatment [12]. Third, many, if not most individuals with FASD entering substance abuse treatment will not be recognized as having FASD. This is especially true in the correctional system [48, 49]. Fourth, very few substance abuse treatment programs have the needed adaptations for clients with FASD. This gap in services may increase their risk of treatment failure and/or relapse. Fifth, treatment strategies of women with FASD should be different from those for men [50]. An essential goal for women with FASD must be to increase their knowledge of the effects of prenatal alcohol exposure and a treatment goal must be no use of alcohol after their child bearing years. This is crucial since no known level of alcohol use during pregnancy has been deemed to be safe. While some interventions focus on birth control, it is also important to acknowledge that this intervention is not 100% effective, and that some women will not adhere to treatment protocols. In the current study, it was estimated that each month women of childbearing age are responsible for about 18 admissions in withdrawal management programs in Canada.

            There are several limitations of the current study that are worth mentioning. First, the prevalence of FASD is unknown in Canada; therefore, for the purpose of this analysis, the most commonly cited rough estimate of the prevalence of FASD (9 per 1,000 [26]) was used, which may not be accurate. Second, the utilization rate of specialized addiction treatment services by individuals with FASD is unknown in Canada; therefore, it was assumed that their utilization rate is the same as those for people with a lifetime mental disorder. Third, the number of individuals with a lifetime mental disorder may be underestimated in the current study due to at least two reasons: 1) self-reported data is a subject to recall bias; and 2) by asking clients to self-report mental diagnoses, those who have not previously sought services or have not received a diagnosis were excluded. As such, using the assumption that the utilization rate of specialized addiction treatment services among individuals with FASD is the same as that of people with a lifetime mental illness, it is likely that the utilization rate of individuals with FASD is also underestimated in the current study.

            The data presented here on the number of women of childbearing age (15 to 44 years) with FASD in substance abuse treatment (approximately 450 admissions) highlights the increased risk for additional FASD cases among the future children of these women. Based on these data, there is an evident need for additional training for programs serving this population. System-wide screening strategies and targeted interventions for women of childbearing age with FASD also need to be developed. These recommendations should be primary prevention priorities for substance abuse prevention programs.

            Conclusions

            Special attention must be paid to at-risk groups of individuals – such as those with FASD, in order to reduce the likelihood of the development of secondary disabilities (in this case, substance abuse problems). Reducing the occurrence of substance abuse problems will alleviate a portion of the costs being allocated to specialized addiction treatment services in Canada, and thus, will reduce the overall burden on Canadian society.

            Abbreviations

            DATIS: 

            Drug and alcohol treatment information system

            FASD: 

            Fetal alcohol spectrum disorder

            FAS: 

            Fetal alcohol syndrome

            Declarations

            Acknowledgements

            This work was supported by the Public Health Agency of Canada [contract # 4500278412].

            In addition, support to the Centre for Addiction and Mental Health for the salaries of scientists and infrastructure has been provided by the Ontario Ministry of Health and Long-Term Care. The views expressed in this manuscript do not necessarily reflect those of the Ontario Ministry of Health and Long-Term Care.

            The authors would also like to thank Kevin Shield for his statistical support, and the DATIS team for providing the data on specialized addiction treatment services from the Drug and Alcohol Treatment Information System.

            Authors’ Affiliations

            (1)
            Social and Epidemiological Research Department, Centre for Addiction and Mental Health
            (2)
            Dalla Lana School of Public Health, University of Toronto
            (3)
            Factor-Inwentash Faculty of Social Work, University of Toronto
            (4)
            Institute of Medicine, University of Toronto
            (5)
            Department of Pediatrics, University of North Dakota School of Medicine
            (6)
            Epidemiological Research Unit, Klinische Psychologie and Psychotherapie, Technische Universität Dresden

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            This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.